<!DOCTYPE html>
<html>
<head>
	<title>全民免费体检报名通道</title>
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	<meta name="viewport" content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no">
	<link rel="stylesheet" type="text/css" href="/templets/phone/css/passageway.css">
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<body class="Contact">
   <div class="box">
      <div class="title">
         免费预约·三甲专家·治疗评估
      </div>
      <form id="myform" action="http://mail.jszjrzk.com/bmi/kuaisu" method="post">
      <ul class="form">
         <li class="clear">
            <div class="left">姓 名：</div>
            <div class="right">
               <input id="name" type="text" name="name"/>
            </div>
         </li>
         <li class="clear">
            <div class="left">电 话：</div>
            <div class="right">
               <input id="phone" type="text" name="phone"/>
            </div>
         </li>
         <li class="clear">
            <div class="left">年 龄：</div>
            <div class="right">
               <input id="age" type="text" name="age"/>
            </div>
         </li>
         <li class="clear">
            <div class="left">性 别：</div>
            <div class="right">
               <label class="radio"><input type="radio" checked="checked" name="sex" value="男"/> 男</label>
               <label class="radio"><input type="radio" name="sex" value="女"/> 女</label>
            </div>
         </li>
         <li class="clear">
            <div class="left">身 高：</div>
            <div class="right">
               <input id="height" type="text" name="hegiht"/><span>CM</span>
            </div>
         </li>
         <li class="clear">
            <div class="left">体 重：</div>
            <div class="right">
               <input id="weight" type="text" name="weight"/><span>K g</span>
            </div>
         </li>
         <li class="clear">
            <div class="left">BMI：</div>
            <div class="right">
               <input id="bmi" type="text" name="bmi" readonly="readonly" />
            </div>
         </li>
         
         <li class="clear">
            <div class="left">体检项目：</div>
            <div class="right">
               <select id="item" name="item">
                  <option selected value="体脂健康综合分析">体脂健康综合分析</option>
                  <option value="血糖检测">血糖检测</option>
               </select>
            </div>
         </li>
         <li class="clear">
            <div class="left">预约时间：</div>
            <div class="right">
               <input id="yuyueshijian" type="date" name="yuyueshijian"/>
            </div>
         </li>
      </ul>
      <div class="footer clear">
         <input id="sub_btn" type="button" value="提交申请" name=""/>
         <input id="reset_btn" type="reset" value="重新填写" name=""/>
      </div>
      </form>
   </div>
</body>
</html>